Provider Demographics
NPI:1073598934
Name:SWAFFORD, LESLIE EUGENE JR (PA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:EUGENE
Last Name:SWAFFORD
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8815 CHRISTENBURY PKWY
Practice Address - Street 2:STE 30
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-0259
Practice Address - Country:US
Practice Address - Phone:704-403-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06035363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2517PAMedicaid
AZ740094Medicaid
NC1073598934Medicaid
NCNCR781EMedicare PIN
NCNCR781BMedicare PIN
AZ105194Medicare ID - Type Unspecified
P57337Medicare UPIN
NCNCR781AMedicare PIN
NC1073598934Medicaid
NCNCR781DMedicare PIN